Neurofeedback for ADHD Treatment in Children



Image courtesy of Wikimedia Commons.
By Carrie Henry

The 5-9% of children in the U.S. with Attention Deficit/Hyperactivity Disorder (ADHD), the most common mental health diagnosis in childhood, are still waiting for the perfect treatment, one that effectively manages unwanted symptoms without side effects and without compromising the benefits ADHD confers. Neurofeedback, a type of biofeedback, offers the promise of just such a panacea. It has demonstrated efficacy in multiple clinical trials, with no reported adverse effects (Cortese et al. 2016). However, a closer look reveals methodological problems with the studies conducted thus far as well as ethical dilemmas related to identity and autonomy. Neurofeedback remains a promising treatment for ADHD, but is not yet “ready for prime time.”

Childhood ADHD: Diagnosis and Prevalence

A diagnosis of ADHD requires evidence of a “persistent pattern of inattention and/or hyperactivity-impulsivity” (American Psychiatric Association 2013, CDC 2018). A child must also exhibit a sufficient number of symptoms over a sufficient period of time, not better-explained by another condition (American Psychiatric Association 2013, Tripp et al. 1999). Children with ADHD tend to experience impaired academic performance, difficulty with peer relationships, and a higher risk of substance abuse (CDC 2013). However, they also tend to be highly creative, energetic, emotionally intelligent, and capable of extraordinary focus on tasks that interest them (de Schipper et al. 2015).

Due to problems with school performance, most families seek medical treatment (usually stimulant medication (CDC 2018)) for their children with ADHD. These drugs have demonstrated only weak evidence of efficacy and are known to cause appetite and sleep problems (Storebø et al. 2018, Punja et al. 2016, Storebø et al. 2015); sleep problems are also associated with hyperactivity and inattention, making these drugs potentially counterproductive (Bijlenga et al. 2019). Concerns about short- and long-term use of these drugs have sent parents and clinicians searching for alternatives (Bussing et al. 2012). Proponents of neurofeedback hope it will be able to decrease unwanted symptoms while otherwise leaving a child’s personality and health intact (Albrecht et al. 2015).

Neurofeedback Basics

Image courtesy of Pixabay.
Since the 1970’s neurofeedback has been investigated and deployed as a treatment for several conditions including ADHD (Hammond 2011). Though there are different treatment modalities, neurofeedback generally involves real-time electroencephalogram (EEG) feedback to teach the patient to change his/her brainwave pattern (INSR N.D.). Electrodes are applied to the patient’s scalp and earlobes and attached to a computer which reads and records specific aspects of the brain’s activity (INSR N.D.). The brain displays several types of brainwaves at any given time, and often the treatment is directed towards shifting the balance between different brainwave types (Hammond 2011). The feedback can be in the form of music, and the sound will waver when the brainwave balance is sub-optimal (Hammond 2011). Over time, the patient learns to control his brainwaves to maintain a pre-defined desired brainwave balance (also causing the music to remain steady), hopefully resulting in changes to the undesirable behaviors (Hammond 2011).

Neurofeedback for ADHD

Several aspects of ADHD make neurofeedback a promising avenue for treatment. One example is the tendency for a brain with ADHD to shift into “resting mode” when it should be focusing on a task (Albrecht et al. 2015). This manifests as inattention or daydreaming and may be reflected on EEG by a shifting balance between “focus” brainwaves and “resting” brainwaves (Albrecht et al. 2015). One target for neurofeedback, therefore, is restoring the dominance of “focus” brainwaves during focused tasks.

The first trial of neurofeedback for ADHD treatment was published in 1995, and treatment protocols and clinical trials have subsequently proliferated (Hammond 2011). An impressive number of studies show positive results, giving the impression that neurofeedback is a well-established treatment for ADHD (Hammond 2011). Unfortunately, there are several challenges inherent in researching treatments of this sort, and most of the studies do not overcome them very well.

Image courtesy of Juligianny at Wikimedia Commons.
One of the thorniest of these methodological problems involves unblinded raters. Most of these studies compare a group of treated children with a group of untreated children before and after the treatment. The raters are usually parents and teachers, with the parents—but not the teachers—being aware whether the child is in the treatment or comparison group (Cortese et al. 2016). The parents tend to report significant improvement in symptoms, but the teachers either do not report a change or report such small improvements that they are unlikely to make a difference in real life (Cortese et al. 2016). This makes it difficult to know whether the change in ratings is due to the neurofeedback or the parents’ belief in the neurofeedback. This and similar shortcomings demonstrate the need for more information before declaring neurofeedback to be a viable treatment option for children with ADHD. 

Ethical Considerations

Recommending a treatment which has not been shown to improve ADHD symptoms is problematic, yet already 10% of children with ADHD receive neurofeedback (CDC 2018). On the other hand, no adverse effects have been reported following neurofeedback for ADHD, so perhaps the worst that could be said is that it exerts nothing but a placebo effect (Cortese et al. 2016, Hammond 2011). There are other ethical conundrums, however, and we will mention two here. The first is the problem of identity, and the second is the problem of autonomy.

Image courtesy of Pixabay.
The problem of identity begins with the diagnosis of ADHD, which brings complicated thoughts and feelings for the children being diagnosed. They identify both positive and negative ramifications including an enhanced self-understanding, the opportunity to identify with others similarly diagnosed, and social alienation and stigmatization (O'Connor et al. 2018). Additionally, many young adult college students who have used stimulants to control their ADHD symptoms for years believe their “real self” is the unmedicated self, but the “medicated self” is the one who can perform in a demanding academic environment incompatible with the distractibility of a brain with ADHD (Loe and Cuttino 2008). These findings suggest that the diagnosis of ADHD is both identity-making and identity-threatening, while the treatment of ADHD is mainly identity-threatening. Children with ADHD may be receiving the harmful message that their “real selves” are unwelcome at school. Even the studies on ADHD treatment only measure the unwanted behaviors and do not include the desirable traits, such as creativity, perseverance, and emotional intelligence, effectively reducing children to their weaknesses rather than their strengths. This problem is not alleviated when the treatment is neurofeedback instead of (or in addition to) medications.

Second is the problem of permanence. It is simply unknown how long the effects of neurofeedback last for children, as studies have not followed participants beyond a year post-treatment (Van Doren et al. 2018). Therefore, the effects of neurofeedback on the developing brain are unknown. Studies have not even begun to investigate whether neurofeedback degrades the desirable aspects of a child’s personality or behavior. A child’s future adult self may well prefer to live as an untreated individual, particularly given the possible advantages conferred by the ADHD itself, including creativity, energy, perseverance, and the ability to tolerate multiple inputs simultaneously (de Schipper et al. 2015). If neurofeedback causes permanent changes, receiving it as a child may preempt that autonomous decision in hopes of obtaining some (as yet unproven) benefit.

While the perfect treatment for ADHD remains elusive, neurofeedback is promising. With well-designed clinical trials and thoughtful consideration of ethical questions, it may soon become another “tool” in the “tool kit” of ADHD treatment.

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Carrie Henry, MSN, RN, is a 2nd-year PhD student in Nursing at Emory University. She has practiced clinically both as a Labor and Delivery nurse and as a nurse-midwife. Her research involves supporting maternal coping following fetal loss. She is the mother of first-grade triplets who keep her very entertained.





References

  1. Albrecht, B., Uebel-von Sandersleben, H., Gevensleben, H., & Rothenberger, A. (2015). Pathophysiology of ADHD and associated problems-starting points for NF interventions? Front Hum Neurosci, 9, 359. doi: 10.3389/fnhum.2015.00359.
  2. American Psychiatric, Association, & D. S. M. Task Force American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders : DSM-5. (5th ed.). Washington, D.C. Arlington, VA: American Psychiatric Association.
  3. Bijlenga, D., Vollebregt, M. A., Kooij, J. J. S., & Arns, M. 2019. The role of the circadian system in the etiology and pathophysiology of ADHD: time to redefine ADHD? ADHD Attention Deficit and Hyperactivity Disorders, 11(1), 5-19. doi: 10.1007/s12402-018-0271-z.
  4. Bussing, R., Koro-Ljungberg, M., Noguchi, K., Mason, D., Mayerson, G., & Garvan, C. W. (2012). Willingness to use ADHD treatments: a mixed methods study of perceptions by adolescents, parents, health professionals and teachers. Soc Sci Med, 74(1), 92-100. doi: 10.1016/j.socscimed.2011.10.009.
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  16. Van Doren, J., Arns, M., Heinrich, H., Vollebregt, M. A., Strehl, U., & Loo, S. (2018). Sustained effects of neurofeedback in adhd: A systematic review and meta-analysis. European Child & Adolescent Psychiatry. doi: 10.1007/s00787-018-1121-4.


Want to cite this post?

Henry, C. (2019). Neurofeedback for ADHD Treatment in Children. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2019/04/neurofeedback-for-adhd-treatment-in.html

Comments

I am an avid reader of the Neuroethics blog and was excited to read Ms. Henry piece on ADHD. The ADHD article draw my attention as I have a child with ADHD myself who is under medication. While reading the article, I was taken aback by the following statement:

These drugs have demonstrated only weak evidence of efficacy and are known to cause appetite and sleep problems (Storebø et al. 2018, Punja et al. 2016, Storebø et al. 2015);

There is 40 years of research showing that the drugs are quite effective. See this meta-analysis from the Lancet I was able to find to draw this point: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30269-4/fulltext#seccestitle140. I noticed that Ms. Henry referenced 3 publications to back up this claim and I found the following in them:

Storebø et al. 2018: "Our certainty in the evidence is very low, and accordingly, it is not possible to accurately estimate the actual risk of adverse events. It might be higher than reported here.Given the possible association between methylphenidate and the adverse events identified, it may be important to identify people who are most susceptible to adverse events. To do this we must undertake large-scale, high-quality RCTs, along with studies aimed at identifying responders and non-responders." This did not make any claim on effectiveness, only side effects.

Punja et al. 2016: "We included 23 studies in this review, 19 of which we included in meta-analyses. Overall, this review found that amphetamines were more efficacious than placebo for reducing ADHD core symptom severity in the short-term, however, they did not influence retention in the trial and were associated with a number of adverse events. According to conventional cut-offs (Cohen 1988), the largest effect sizes observed (i.e. an SMD > 0.8) were teacher ratings of hyperactivity/impulsivity, teacher ratings of inattention, and clinician ratings of total ADHD symptoms. The meta-analyses with the most available data included parent and teacher ratings of total ADHD symptoms, both of which yielded low to moderate effect sizes. The median study duration was only 28 days, therefore it was not possible to assess the long-term efficacy and safety of amphetamines for pediatric ADHD. This is particularly problematic in a condition such as ADHD, which may require treatment for years." This study seem to indicate there is efficacy in the short term but that it was not possible to assess the long-term efficacy. It did not say the drugs were not efficacious.

Storebø et al. 2015: "The results suggest that among children and adolescents with a diagnosis of ADHD, methylphenidate may improve teacher reported symptoms of ADHD and general behaviour and parent reported quality of life. However, given the risk of bias in the included studies, and the very low quality of outcomes, the magnitude of the effects is uncertain. Methylphenidate is associated with an increased risk of non-serious but not serious adverse events." Similarly as the article in 2018, they are not claiming lack of efficacy.

I agree with Ms. Henry that these drugs are not a “silver bullet” and there is a lot of trial an error with them as they have a great variability among patients, and some kids may not benefit from them. But claiming they are not efficacious goes against what it is well-known and reported.

Sorry for being a pest, but these seems to be an oversight and I thought I would be good to bring this to your attention.
Carrie Henry said…
Dear Maica Guerrero Davila,
Thank you very much for pointing out where I was unclear. I did not mean to imply that clinical trials of stimulant drugs for ADHD have not shown statistically and clinically significant results; indeed they have. Also, I agree that the positive experiences of many, many families using stimulants for ADHD treatment is valuable information. My assessment of "weak evidence" was based on the very two problems you pointed out: a high risk of bias in the studies (Punja, et al, 2016; Storebo, et al., 2015) and the short duration of follow-up in the studies (most < 12 months) (Punja, et al., 2016). The risk of bias is particularly concerning, leading the authors of both Cochrane reviews to classify the evidence for improved outcomes as "very low" (Punja, et al, 2016; Storebo, et al., 2015). There may be more recent, better-designed studies since those reviews were published, so the question is certainly not closed. I do think it is clear to both of us that stimulants are not the "magic bullet" parents, clinicians, and children are seeking. I appreciate your reading my post, and for the chance to clarify my meaning.

Best regards,
Carrie Henry

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